Holistic care: key to resolving rising geriatric problems

Sri Lanka’s elderly population, poised to double its present rate by 2040 will pose a formidable challenge to our health care system already reeling from heavy expenditure spent on treating the multiple problems that most elders have.

The Sunday Observer spoke to Consultant Physician, Colombo South Teaching Hospital, Kalubowila, Dr Dilhar Samaraweera, who has done an intensive study on Geriatrics which is still not well understood in Sri Lanka, to give us more insights into the problems likely to challenge, both, the elderly population and our health care system in the not too distant future.

Excerpts

Q. With an aging population that is rapidly growing, compared to other fast developing countries, how would you rate Sri Lanka’s population growth?

A. Sri Lanka has one of the most rapidly aging populations in the world. Every one out of four will be elderly by year 2041.This increase is predicted to occur in just 23 years. The country is experiencing a demographic transition, which is likely to strain the current health care system which is not geared to take care of the rapidly aging population. The rapid increase in the elderly population is taking place without a major change in the infrastructure and per capita level of income. Thus, Sri Lanka will need a spectacular rate of economic growth to provide health care services for this rapidly aging population.

Q. What age group does an elderly person fall into?

A. In less developed countries an elder is considered as over 60 years. In the western world it is over 65 years.

Q. What are the main problems associated with old age?

A. Mental Health problems of the elderly is one of the main problems that comes with old age. Mental health problems common in old age includes the following conditions; Dementia, Delirium, Depression , Organic mood disorders and organic delusional disorders.

Q. What triggers these conditions?

A. Sedentary lifestyle, shift from suburban extended family living to complex nuclear family living, change in social contact.

Q. Apart from their mental health impacts , many elders also suffer from several physical problems that affect their health. Tell us what they are.

They are also at risk of impairment of hearing and vision, likely to have problems with gait, balance and experience falls. Incontinence of bladder and bowels, is another common problem. So is poor nutritional status, Osteoarthritis and Osteoporosis. All these impede their activities of daily living.

Q. Q. Are they different from elders living in urban environments and those in rural environments? Why?

A. In the case of mental health problems, elders living in rural environments live in their own villages with the extended family. Thus they are unlikely to experience loneliness, isolation, depression. However, the physical problems in urban and rural communities are similar.

Q. How has the intrusion of hi tech and demographic shift or population and other factors influenced these changes?

A. An erosion in the cultural values of our society and extended family has come under strain due to a decrease in the number in a family, and also as a result of internal and external migration. The extended family is helpful in preventing institutionalizing of the elderly, but at the same time has been a cause for family disputes between in laws. The busy lives due to urbanization and lack of physical activity and socialization has resulted in obesity and associated cardiovascular diseases and poor communication among members of the family resulting in isolation and depressive disorders.

Q. What problems do you see regarding geriatric care in the future in Sri Lanka?

A. There has been a paradigm shift from increased prevalence of non communicable diseases to communicable diseases. The development of the infrastructure facilities and equity in health care resulted in a decrease in communicable diseases. The change in lifestyle diet also has contributed to the increased incidence of non communicable diseases. More people are living into old age due to advanced treatment of myocardial infarction and stroke and other diseases. The prevalence of multiple diseases will result in elders being on multiple drugs, which results in adverse effects of drugs and also will be a financial burden with poverty in old age.

Q. What are the most formidable health challenges geriatrics face ?

A. As we grow old our muscles and bones become weak. The result is poor mobility. The poor mobility further leads to regression of bones leading to osteoporosis and falls and fractures which result in restriction of movement and even death. Impairment in memory leading to dementia, cognitive impairment and other mood disorders which occur as a result of isolation of elders also lead to a reduction of our functional abilities.

Sensory problems such as, hearing and vision deficiencies further complicate lives of the elderly. It is important to correct the sensory impairments which enable the elderly to actively participate in family and social activities.

Sensory problems should not be taken for granted in the elderly. Being physically and mentally active and engaging in social activities will enable the elderly to delay dementia and reduced mobility and falls.

Q. Do you have statistics or percentages of elders with NCDs? Has there been a national survey on them in recent years?

A. The recently published National Survey on Self-reported health in Sri Lanka comprises data throughout 2014 from 25,000 households covering all districts in the country. It is the first household survey on health.

A total of 55.2% of respondents aged 60 or older reported having at least one chronic disease. In respondents aged 65 or older, 18.1% reported having Diabetes, 30.4% hypertension, 6.6% Asthma, and 8.8% reported having arthritis. The survey also showed that 65% of elderly had poor vision, 2% had no vision and 28% had poor hearing, 2% had no hearing at all. Joint pains and difficulty in movement was the commonest illness among the elderly according to this survey.

Q. So do you agree there is now an explosion of NCDs in our country ?

A. The health indices of the country have improved, the prevalence of communicable diseases have decreased significantly due to effective treatment, immunization and successful preventive programs. The introduction of machinery, transportation and the busy life patterns with long working hours with less time for exercises and recreational activities has also contributed to the increase in obesity, hypertension, diabetes mellitus, ischemic heart diseases and stroke. The increased environmental pollution with the increased vehicle traffic has resulted in the increased incidence of respiratory diseases such as asthma and chronic obstructive airway lung disease and lung cancer, as well as road traffic accidents.

Q. Are they preventable?

A. Non communicable diseases are preventable. Having a healthy diet with physical activities and lifestyle modifications and avoidance of bad habits such as smoking and excessive alcohol can keep NCDs at bay. Most NCDs are not curable, but can be managed without complications.

Q. Do we have enough facilities for this?

A. Infrastructure facilities have been developed to detect and manage NCDs at an early stage. Healthy Life Style clinics have been established island wide to screen for diabetes and people with increased cardiovascular disease who will receive health messages and follow up.

Well Woman Clinics are conducted for females as a screening clinic which include pap smear investigations. There are also many public health programs to prevent diseases and promote health services at community level for the elderly. National program for the prevention of deafness and hearing impairment, Vision 2020 program to prevent blindness and treatment for cataract carry out activities at community level.

Q. As a geriatric specialist what do you consider as the most urgent needs for them?

A. They need easy access to health care facilities. They also need a social security mechanism which ensures health care during old age. No insurance policy covers the elderly, most policies end around 55 years of age. Very few elders receive a pension. More hospitals should be upgraded to provide accessibility to elders.

Elderly patients’ problems are quite different from that of the young, thus multidisciplinary teams consisting of doctors, nurses, physiotherapists and occupational therapists, dieticians and speech language therapists are needed to care for them.

Q. Are hospitals ready for this challenge?

A. The hospitals in the country cater to all age groups at present. Elderly health care services are operated through the existing health system in the country. Health authorities are focusing more to provide quality care for elderly through improving infrastructure facilities, human resource and capacity building at both, curative and preventive sectors.

At present, the elderly are treated by the General Physicians in the General Medical wards. It is difficult to build dedicated elderly care units with specialized staff to manage elderly, especially, in a resource poor setting. Thus, the way forward would be to enable better care for the elderly in the General Medical wards .

In the busy General Medical wards there is a rapid turnover of patients and there is high demand for beds. Thus, it is difficult to rehabilitate the elderly after acute illnesses in these wards. Multidisciplinary staff is a luxury which is only available in stroke units and some orthopedic wards. Reorientation should pay attention to allocation of a number of beds for the elderly in each General Medical ward and also providing multidisciplinary staff to support the elderly patients in the General Medical wards.

The Health Ministry has also taken measures to train more health personnel to overcome problems of curative resources. Dedicated wards for elderly care are being set up with multidisciplinary teams to improve care of the elderly.

Q. Home care, although the most common type of care given to elderly persons by family, neighbours and friends, still has some gaps. Your comments?

A. Extended family setup is an asset, as patients are being discharged prematurely due to pressure of beds and high turnover in the medical wards. At present educating the informal care givers in the extended family and strengthening them would be the best way of looking after them.

A. Services provided by private hospitals takes a certain amount of workload from the government sector. However, the long-term care be it private or public is costly. Establishment of a social security system would be the way forward.

A. Elders in general should maintain a healthy lifestyle and have a healthy diet, with adequate amount of protein to reduce muscle wasting in old age. The low protein content in their diet results in loss of strength and muscle mass, leading to falls and fractures resulting in disability and death.

Elderly patients pose many challenges to the physician. The presentation of diseases in elderly are very non specific as they have multiple non communicable and degenerative diseases and are on multiple medications.

The holistic approach, vital especially, in managing elderly patients can be achieved best by a multidisciplinary team. Comprehensive Assessment which is the gold standard for management of the frail elderly cannot be accomplished without the support of an interdisciplinary team.

The skills, knowledge and expertise of the different members of the team can be combined to effectively manage the complexities of the elderly patient and provide better care.